Basic Information
| Provider Information | |||||||||
| NPI: | 1588743215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 JACK LITTLE RD | ||||||||
| Address2: | |||||||||
| City: | SARDIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383714035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318582192 | ||||||||
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| Practice Location | |||||||||
| Address1: | 524 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECATURVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383298101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318523591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3106 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.